There's a cementing — but collegial — "old school" and "new school" divide in type 2 diabetes care.

David Nathan, director of the Diabetes Center at Massachusetts General Hospital, says he's been called a Luddite because he's pretty skeptical about how often other physicians in the field prescribe newer diabetes-treatment drugs.

"In general, having a large choice of medicines to choose from is a good thing," Nathan said. "The active debate that's going on within the diabetes community is: What is the relative worth of these new drugs, especially because they all cost more than the older drugs?"

Metformin, sulfonylureas, and insulin are staples in the traditional arsenal of diabetes drugs. Each medication—old and new—has a unique way of working in the body; but, in general, the goal is to control blood sugar—that in high doses over time—can damage the vessels that supply blood to vital organs.

Some of the newer drugs include sitagliptin from Merck, sold under the brand Januvia, and Invokana from Janssen Pharmaceuticals.

Nathan is on the record that he often favors older diabetes drugs, which have a longer track record and more familiar risks.

Meanwhile, some industry trackers argue that just because a medicine was approved a decade ago does not mean it's safer.

Invokana, approved earlier this year, works in the kidneys to divert sugar to the urine, which keeps less glucose from reaching the blood stream.

"It may cause urinary tract infections," Nathan said. "These drugs all have benefits and advantages, and they all have disadvantages."

New research is underway that may help referee the debate, but critics say, in the meantime, the competition among drug companies is intense, and so is their direct-to-consumer advertising.

While many physicians are "Nathan protégées" others, including Serge Jabbour, cite a longer list of advantages from the new medicines.

Jabbour, who leads the endocrine division at Jefferson Hospital, said he's a fan because the newer drugs, introduced in the mid-2000s and later, are less likely to cause "hypoglycemic events."

"Just image an older person having a low-sugar reaction," Jabbour said. "They can lose consciousness, they can fall, they can have a hip fracture."

Some of the newer drugs classes also help patients lose weight which can benefit cholesterol, the heart, and decrease sleep apnea.

Cost considerations

Those advantages, Jabbour said, can outweigh the increased price tag — as long as a patient has insurance.

Co-payments range from $20 to $60, he said. Patients paying in cash without health care coverage might spend $300 or $400 a month.

In 2012, the United States spent $176 billion in direct medical costs on diabetes care. About two million new adults are diagnosed with diabetes in the U.S. each year, most of them with type 2 diabetes.

"We can literally bankrupt the system because of this epidemic of diabetes and the introduction of a lot of new and expensive drugs," Nathan said.

Patient concerns

Nathan was in Philadelphia this month for a summit organized by the Thomas Jefferson University — and reminded the crowd about some of obesity trends driving the type 2 diabetes epidemic.

"Compared to 30 years ago, most of us sit down most of the day at our jobs in front of a screen and don't walk very much," he said. "And at the same time, we go off to lunch and have a high-calorie meal and before you know it, with increasing aging we're gaining pound after pound."

Most people with diabetes eventually need two medications to keep blood sugar in check. At the summit, several doctors spoke about their patients' reluctance to begin diabetes drug treatment, especially if they are already taking a cholesterol medicine or drugs to manage high-blood pressure.

"Nobody wants to be taking six, seven, eight, nine, 10 drugs, so we need to try to minimize that as well," Nathan said. "Which means generally that you have to take the drugs that are slightly more powerful."